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~ I A II:. UF Nt:W YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and I'
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
RQQQrt L. Cra''''~RENTSURNAME
COUNTY Dutchess
CITYfroWN \^!iippinger
~iJJ:~cJ 1366
~G~~J~R 1 Q6
1. A. FUll NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 125 56 1660
2. RESIDENCEA. N ~ATE) B. D~so
C. CHECK ONE .$l CITY 0 TOWN 0 VIlLAGE
AND
SPECIFY PoughkoepGio
D. STREET ADDRESS 104 Winnikee /wenue, Apt. ZIP 12601
E. is RESIDENCE WI1H'iN UMITS OF CfIY OR INCORPORATED V1UAGE? ~ YES 0 NO
~ /~a /~4
3. A. AGE20
4. EMPLOYMENT
3B. DATE OF BIR1l-I
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS Bol3'o Store
5. PLACEOFBIRTHp~~) Yorl(
6. FATHER
....
:>
<C
A. NAME Robert Craves
B. COUNTRY OF BIRTH U 8 ^
7. MOTHER
A. MAIDEN NAME SaUlldra Browll
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0
2ND 0 0
3RD 0 0
4TH 0
I, being duly sworn, depose and say, that to the best of my knowledge an
as to my right to enter into the manjage state.
-"
21. SIGNATURE OF GROOM ~ L
""",'1;; riL.l: ..UMDl;;n
(TH/S SPACE FOR STA TE USE ONL Y)
") ,
~/V~ ,It/-?>
L 0 SUPPLEMENTAL FILE
~
FROM THE BRIDE
11. A. FUll NAME FIRST OI~A. )(za'ViElfilRENTSURNAME
B. BIRTH NAME (MAIDEN NAME), IF DiFFERENT 110 II
C. SURNAME AFTER MARRIAGE V~a' ",'an
(OPTIONAL. SEE REVERSE)''"' v '"'
D. SOCIAL SECURITY NUMBER 575-09-1907
12. RESIDENCE A'NeiMN~)rk B. Ortam~
c. ~6CK ONE 0 CITY 0 TOWN I;iiI VILLAGE
SPECiFY Moybrool<
D. STREET ADDRESS52Ei S:lraoino Drive ZIP 12543
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE? 0
13. A. AGE28 13.B. DATE OF BIRTH tla1TH / M.y
14. EMPLOYMENT
Y~ NO
rlA
A. USUAL OCCUPATION Nurse
B. TYPE OF INDUSTRY OR BUSINESS 8 &. 0 Ilealth Cafe
15. PLACE OF BIRTH~irR~~ M;~rk
16. FATHER
A. NAMEGereld 11011
B. COUNTRY OF BIRTIU 6 A
17. MOTHER
A. MAIDEN NAME Mih..lIl::J Mli Ndil
B. COUNTRY OF BIRnU S A
18. NUMBER OF THIS MARRIAGE 2
19. PREViOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) \,1 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? .d!:l /!la / ",.....'1
MONTH! L. WAif) ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? ijl YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY,IF NOT USA) SELF SPOUSE
o ~
o 0
o 0
o 0
that no legal im~ediment exists
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK.
This license authorizes the marriage in New York State f the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
w
en
z
w
o
;:j
,-"-..
{ SEAL }
'-v-I
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
ATE12/26/2002
AM
PM 12 27 2002 02 24 2003
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~"^-~ ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF~TOWN OF 0 VILLAGE OF
1 :24
IP
S
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TAT
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
l.~VIL
29. OFFICIANT
NAME (PRINT)
STREET
30. WITNESS TO CEREMONY
I
NAME (PRINT) ~ 0.....("\ \ e \ \ r C L e (\ t"'
SIGNATURE. r-;]y.\..f"\ \ , I \ 1 c.. U;--:=-
DOH-98 (11/98)
SPECIFY , .l J6..ff i v..-.-s-e.r
31. WITNESS TO
NAME (PRINT)
SIGNATURE ~